I'm a Visiting Professor at Cardozo Law School where my research focuses on media law with a particular focus on law and social media. Previously, I was the Editorial Counsel for Forbes magazine and Forbes.com. E-mail me at kai.falkenberg@yu.edu.

Why Rating Your Doctor Is Bad For Your Health

THE MATH IS NOW SIMPLE FOR DOCTORS: More tests and stronger drugs equal more satisfied patients, and more satisfied patients equal more pay. The biggest loser: the patient, who may not receive appropriate care.

“By creating a monetary incentive to increase patient satisfaction, the government is not only increasing its expenses but promoting a metric that significantly increases death rates,” says William P. Sullivan, an emergency room doctor in Spring Valley, Ill. He’s a long-time critic of patient surveys.

Another emergency room doctor in Columbia, S.C., who requested that we withhold his name, walked us through how this plays out in real life. Between 5% and 7% of his compensation–some $10,000–is dependent on high Press Ganey scores. So when the family of an elderly woman insisted that she be admitted to the hospital after stroke-like symptoms, he agreed to do so, even though her test results were negative and he wanted to send her home. “Her family refused, and they told me so,” he recalls. “Do I call security and escort them out? I was more concerned with them giving me a bad patient-satisfaction survey score than her going home and having a stroke,” which he considered highly unlikely. In admitting the patient, he exposed her to hospital-borne infections and, worse, a hefty bill for, as he puts it, “us doing nothing since she didn’t satisfy the criteria for admission.”

These ethical dilemmas are playing out across the country, with the need to please customers often trumping their health. In a recent online survey of 700-plus emergency room doctors by Emergency Physicians Monthly, 59% admitted they increased the number of tests they performed because of patient satisfaction surveys. The South Carolina Medical Association asked its members whether they’d ever ordered a test they felt was inappropriate because of such pressures, and 55% of 131 respondents said yes. Nearly half said they’d improperly prescribed antibiotics and narcotic pain medication in direct response to patient satisfaction surveys.

One emergency room with poor survey scores started offering Vicodin “goody bags” to discharged patients in order to improve their ratings. And doctors face the reality that uncomfortable discussions on behavioral topics–say, smoking or obesity–come with the risk of a pay cut. “The challenge is how do we discuss this with the patient so the patient doesn’t leave unhappy,” addiction specialist Dr. Aleksandra Zgierska recently told the AMA’s American Medical News. “Saying yes is easy.”

OVERTREATMENT IS MORE THAN A SILENT KILLER. It’s cripplingly expensive. Drill down to almost any procedure that keeps skittish patients happy and the price tag is enormous. Overused prostate cancer screenings? At least $3 billion a year. Unnecessary antibiotics? Another $1 billion annually–with the added harm of creating drug-resistant bacteria. All told, overtreatment accounted for up to $226 billion in 2011, for things like unnecessary procedures and prescriptions that don’t help patients. That’s according to Donald M. Berwick, the former administrator of the Centers for Medicare & Medicaid Services (CMS), which oversees those programs. Another $55 billion a year is directly tied to the abuse of prescribed opiates. Ironic, since government-mandated surveys were supposed to cut medical costs.

Until the government got involved, surveying patients was a sleepy niche business. Then, in 2002, CMS announced a national program to survey patients and require public reporting of the results. The move was part of a Bush Administration initiative to improve accountability and public disclosure and to empower patients to make more informed decisions about health care.

Instead, that move empowered Press Ganey. When it was founded in 1985 by an anthropologist and a sociologist from Notre Dame, just a handful of hospitals routinely asked patients if they were happy with the care they received. The practice expanded gradually by the late 1990s. The federal mandate transformed a voluntary expense into a compulsory one, increasing demand exponentially. Hospitals had to turn to companies like Press Ganey, which administers the federal survey for them and rates other units not covered by the mandate, like the ER.

Investors have also reaped the rewards. Press Ganey was taken private in 2003 by American Securities, a New York private equity firm, for a reported $100 million. Four years later it was flipped to another private equity outfit, Vestar, for a reported $673 million. Since then revenue at Press Ganey has grown at high single digits; it earned $82 million (Ebitda) on $217 million in sales in 2011.

ObamaCare’s “pay-for-performance” program is providing yet another boost. Starting last October, hospitals that perform poorly on quality measures forfeit 1% of their Medicare payments, a number that doubles by 2017, putting some $2 billion at risk. Thirty percent of that determination will be based on the hospital rankings from mandated patient surveys. That means, in some cases, hospitals are throwing money at things like new elevators and valet parking. It means doctors will be under yet more pressure to give their customers what they want.

And it means ever more clout for operations like Press Ganey. It processed 70 million patient surveys last year from 10,000-plus health care organizations and half of all U.S. hospitals. And it stands to gain even more from groups like the Cleveland Clinic, which already spends $500,000 a year on government-dictated surveys.

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Patient satisfaction is an important outcome. Patients deserve to have a voice. Appropriate scientific methods and reliable data are incredibly important. As your report observes, a handful of surveys is not an adequate sample size for benchmarking and incentivizing performance.

Yes, indeed. My story is encapsulated in the graphic that shows the report posted in a physicians lounge. The important thing is to measure patient satisfaction in an evidence-based way — encouranging physicians to similarly practice evidenced-based medicine.

I am one of those healthcare providers who have been asked to resign, not fired, a number of times because of patient complaints. Because of that I wrote and published a book titled The Customer is NEVER Right: A Nurse Practitioner’s Perspective in 2012, to tell my story knowing it is the story of many healthcare workers. Recently, I asked a colleague to look at my blog (www.thecustomerisneverright.com) and he replied, “A not so recent article that [found] patients with [customer satisfaction] scores of 5 have the highest mortality.” Baffled by his claim, I set out to find the article he mentioned to include in my blog and serendipitously found the article you published.

This is the book’s synopsis: An earnest yet unsettling account of frontline emergency healthcare in the USA today from the point of view of one man, a nurse practitioner, who struggles to maintain his integrity and his job, and, ultimately, failing, at least in terms of the job. Honesty and agony jump off the page as the author points out the serious problems between healthcare administrations and the transformation of healthcare from a helping profession to just one more profit-driven business.

Healthcare is a time honored profession and the practice of medicine must remain evidence based and not about catering to arbitrary satisfaction scores. Medicine is not Facebook and we should not be concerned by being “liked” or “friended”.

Ms. Falkenberg, you have written a superb article that draws attention to a number of pressing healthcare issues, as does my book, however, we both seem to be preaching to the choir. These issues have been mentioned a number of times before, by a number of authors, in a number of mediums, and continue to fail in grabbing the attention of administrators and policy makers as if they are not paying attention or are not remotely interested, a poignant point I outline in my book.

The purpose of me joining this discussion is to highlight the fact that, even though you are not affiliated with healthcare as your primary profession, you came up with the same objective findings that I, and the many that have replied to your article, have come up with. As noted by your followers’ replies, healthcare workers likely have ten stories for every story you and I could share. Having said that, health care workers are not sniveling as the PG CEO suggested when he exclaimed, “Suck it up.”

Now, we in healthcare can only hope administrators and policy makers will consider your story as neutral, as you do not have a reason to grumble, because our attempts to bring the same pivotal findings to anyone’s attention have fallen on deaf ears.

The train may have left the station, as the PG CEO tells physician groups, but it has gone down the wrong track. Medical care should never come second to customer satisfaction. Not to mention the trail of collateral damage left behind from catering to patients with exaggerated unrealistic emotional expectations. With that said, history bears witness that bad ideas are successful when do-gooders stand by and let the train run down the wrong tracks.

Thank you for writing such a timely, critical, and informative article and hopefully with your investigative journalism and our desire to keep healthcare an honorable profession, we can expose the insidious practice that customer satisfaction rating is in healthcare.

I am one of those healthcare providers who have been asked to resign, not fired, a number of times because of patient complaints. Because of that I wrote and published a book titled The Customer is NEVER Right: A Nurse Practitioner’s Perspective in 2012, to tell my story knowing it is the story of many healthcare workers. Recently, I asked a colleague to look at my blog (www.thecustomerisneverright.com) and he replied, “A not so recent article [found] patients with [customer satisfaction] scores of 5 have the highest mortality.” Baffled by his claim, I set out to find the article he mentioned to include in my blog and serendipitously found the article you published.

This is the book’s synopsis: An earnest yet unsettling account of frontline emergency healthcare in the USA today from the point of view of one man, a nurse practitioner, who struggles to maintain his integrity and his job, and, ultimately, failing, at least in terms of the job. Honesty and agony jump off the page as the author points out the serious problems between healthcare administrations and the transformation of healthcare from a helping profession to just one more profit-driven business.

Healthcare is a time honored profession and the practice of medicine must remain evidence based and not about catering to arbitrary satisfaction scores. Medicine is not Facebook and we should not be concerned by being “liked” or “friended”.

Ms. Falkenberg, you have written a superb article that draws attention to a number of pressing healthcare issues, as does my book, however, we both seem to be preaching to the choir. These issues have been mentioned a number of times before, by a number of authors, in a number of mediums, and continue to fail in grabbing the attention of administrators and policy makers as if they are not paying attention or are not remotely interested, a poignant point I outline in my book.

The purpose of me joining this discussion is to highlight the fact that, even though you are not affiliated with healthcare as your primary profession, you came up with the same objective findings that I, and the many that have replied to your article, have come up with. As noted by your followers’ replies, healthcare workers likely have ten stories for every story you and I could share. Having said that, health care workers are not sniveling as the PG CEO suggested when he exclaimed, “Suck it up.”

Now, we in healthcare can only hope administrators and policy makers will consider your story as neutral, as you do not have a reason to grumble, because our attempts to bring the same pivotal findings to anyone’s attention have fallen on deaf ears.

The train may have left the station, as the PG CEO tells physician groups, but it has gone down the wrong track. Medical care should never come second to customer satisfaction. Not to mention the trail of collateral damage left behind from catering to patients with exaggerated unrealistic emotional expectations. With that said, history bears witness that bad ideas are successful when do-gooders stand by and let the train run down the wrong tracks.

Thank you for writing such a timely, critical, and informative article and hopefully with your investigative journalism and our desire to keep healthcare an honorable profession, we can expose the insidious practice that customer satisfaction rating is in healthcare.

I am one of those healthcare providers who have been asked to resign, not fired, a number of times because of patient complaints. Because of that I wrote and published a book titled The Customer is NEVER Right: A Nurse Practitioner’s Perspective in 2012, to tell my story knowing it is the story of many healthcare workers. Recently, I asked a colleague to look at my blog (www.thecustomerisneverright.com) and he replied, “A not so recent article [found] patients with [customer satisfaction] scores of 5 have the highest mortality.” Baffled by his claim, I set out to find the article he mentioned to include in my blog and serendipitously found the article you published.

This is the book’s synopsis: An earnest yet unsettling account of frontline emergency healthcare in the USA today from the point of view of one man, a nurse practitioner, who struggles to maintain his integrity and his job, and, ultimately, failing, at least in terms of the job. Honesty and agony jump off the page as the author points out the serious problems between healthcare administrations and the transformation of healthcare from a helping profession to just one more profit-driven business.

Healthcare is a time honored profession and the practice of medicine must remain evidence based and not about catering to arbitrary satisfaction scores. Medicine is not Facebook and we should not be concerned by being “liked” or “friended”.

Ms. Falkenberg, you have written a superb article that draws attention to a number of pressing healthcare issues, as does my book, however, we both seem to be preaching to the choir. These issues have been mentioned a number of times before, by a number of authors, in a number of mediums, and continue to fail in grabbing the attention of administrators and policy makers as if they are not paying attention or are not remotely interested, a poignant point I outline in my book.

The purpose of me joining this discussion is to highlight the fact that, even though you are not affiliated with healthcare as your primary profession, you came up with the same objective findings that I, and the many that have replied to your article, have come up with. As noted by your followers’ replies, healthcare workers likely have ten stories for every story you and I could share. Having said that, health care workers are not sniveling as the PG CEO suggested when he exclaimed, “Suck it up.”

Now, we in healthcare can only hope administrators and policy makers will consider your story as neutral, as you do not have a reason to grumble, because our attempts to bring the same pivotal findings to anyone’s attention have fallen on deaf ears.

The train may have left the station, as the PG CEO tells physician groups, but it has gone down the wrong track. Medical care should never come second to customer satisfaction. Not to mention the trail of collateral damage left behind from catering to patients with exaggerated unrealistic emotional expectations. With that said, history bears witness that bad ideas are successful when do-gooders stand by and let the train run down the wrong tracks.

Thank you for writing such a timely, critical, and informative article and hopefully with your investigative journalism and our desire to keep healthcare an honorable profession, we can expose the insidious practice that customer satisfaction rating is in healthcare.

Kai, contact me. This article touches base on many of the reasons I left my position of 12 years to develop the cloud app that addresses these and many other concerns. In this early day of mHealth it is time to lead.

The problem with this type of data collection and reporting has always been reliable data.

I would love to offer several of the Drs frustrated with current industry standard(within this post) the opportunity to help lead and develop this methodology by piloting this app in their practice for a year.

Everyone has been talking about this nonsense for years. My team and I are ready to offer the solution.

Patients do have a voice. They can vote with their feet. At our facilty we have had vastly different ratings on the same question, THE COMFORT OF THE WAITING ROOM, by different doctors whose patients all use the same waiting room. We have had ‘ratings’ when only 3 surveys were returned, that can’t be valid data.

This article raises legitimate concerns. I am an RN at on psychiatric unit in a hospital. Same thing is being incorporated into our system. Whether it works in a medical unit, I won’t speak to that, but psychiatric? no way! Doctors end up prescribing narcotics to already addicted psychiatric patients who are coming into the hospital claiming to be suicidal only to be prescribed the pain pills they can’t afford off the street and can’t get a doctor to prescribe for them on the outside. These are patients who are clearly not in pain as they flint around the unit socializing with others like they are on a cruise ship. Many psychiatric patients are unhappy and they are not in a frame of mind to do anything but complain. My specific area gets a lot of personality disorders who thrive on chaos, try to create chaos, split staff, push limits, disobey rules. When they don’t get away with their childish antics, when they are confronted on their behavior and how it is impeding their ability to get along in the “world” they can become angry and punitive. Punitive especially when asked about patient satisfaction. It’s their chance to seek revenge because they don’t want to change their misguided and maladjusted ways of coping with the world’s stresses. We end up allowing them to get away with anything and the unit begins to resemble a playroom where wild and misbehaved 2 year olds have taken control of their caregivers. Sounds good in theory, does not work in real life. In fact, like the article says, it ends up impeding getting the care the patient actually needs.

Thanks for sharing your experience. Given the epidemic of prescription narcotic abuse, its disconcerting that we are incentivizing docs to prescribe even more drugs. I appreciate you adding your first hand perspective to this conversation.